GW1-2022-03544_Well Construction - GW1_20220322

+YELL C0NSTKUCT_12
w For Internal Use On j 0 I I C
n—
x_•Well Contractor Information: 14.WATER: = —
Kevin Letchworth
FROM TO DESCRIPTION
ft. rL ^•
,dell Contractor Name r�� ft.
2514A J
15:OUTER,CASING for midti=ca wells OR LINER if a llMAITERIAL
DIAMETER THICKNESS J
NC Well Contractor Certification Number FROM TO ft / c, in p
N.W. Poole Well & Pump Co. ft. l'
16 1NNER.CASING OR TUDING. eotbeii6al eloC�E55 MATERIAL
m
Company Name FROM TO DIAMETER; T
ft.
ft. in.
2.Well Construction Permit#: to
List all applicable well construction permits(,, UIC,County,State,Variance,ere.) ft. ft.
3•Well Use(check well use): 17.SCREEN TffiCKNESS MATERIAL
FROM TO DIAMETER SLOT SIZE
Water Supply Well: tt• g in.
❑Agricultural
j&unicipal/Public
ft. 1D'
OGeothennal(Heating/ Supply) ❑Residential Water Supply(single) ft.
❑Residential.Water Supply(shared) 18:GROUT: EMPLACEMENT METHOD&AMOUNT
❑industrial/Commercial FROM TO MATERIAL r
❑Wells>100 000 GPD ft• ft. v�!
❑Uri ation
Non-Water Supply Well' ft. tt.
❑Recovery
❑Monitoring ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if-a" licable: - EMPLACEMENTMETHOD
FROM TO MATERIAL
❑Salinity Barrier tt tt:
❑Aquifer Storage and Recovery ❑Stormwater Drainage
❑Aquifer Test
❑Subsidence Control
❑Experimental Technology -20.DRILLING LOG Attach lkil tio6'Aisheets if:necess
❑Tracer FROM TO DESCRIPT ON color hardness sorllrock
OGeothermal(Closed Loop) a rains etc.
�11)1 �31; nder#21 Remarks © tL Q tt. r
,2G eothermal(HeatinglCooling RetumCt ft 81 ft /S
S �u
Q ft.
hate VVell(s)Completed:� ft.
tt.Well Location: IL
Facility ID#(if applicable)
Facility/ net Name
MAR
Fl I&Liysical Address,'City,:and Zip n n r� / 21.REMARKS f
GJ� S`�l ( Used hardened steebdrlveshoe
Parcel Identification No.(PIN)
Lonny
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
f well field,one tat/long is sufficient) 1r2
3�c ��c/�� N W
JJ D to
= Signature of Certified Well Contrac or
d'ermanent or ❑Temporary rote constructed inaccordance+vfth
�.Is(are)the well(S): By signing thisC.010 hereby certify that the n'ell(s),vas( )
I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Coauruclion Standards and drat a copy
Is this a repair to an existing well:
Dyes or t 0 of this record has been provided to the mell owner.
;fihis is a repair,fill out known well construction information and explain tie nature of the 23.Site diagram or additiooal'we1►details:
,pair under 021 remarks seclion or on the back of this form.
You may use the back of this page to provide ad, naI well construction info
'.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'See Over in Remarks Box).You may also atta4dditional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells 24.SUBMITTAL INSTRUCTIONS
drilled:
s, ace:
Total well depth below land surf
(ft,) Submit this GW-1 within 30 days of well comply per the following:
Per•rnuhiple wells list all depths ifoliferent(example•3(a3200'and 2(a�100) 24a. For All Wells: Original form to Divisior Water Resources (DWR),
le.static water level below top of casing:
(fG) Information Processing Unit,I617 MSC,Raleigh,27699-1617
;''water level is above casing,use"+'.; l/ 24b.For Infection Wells:Copy to DWR Unde'nd Injection Control(IUC)
t1 (in,) Program,1636 MSC,Raleigh,NC 27699-1636
.I-Borehole diameter:
Ql� �/Jy 24c.For Water Su 1 and O en-Loo Geoth Return Wells:Copy to the
@ Well construction method: county environmental healt epartment of the co ere instal ed
,I.e.auger,rotary,cable,direct push etc.)
24d.For Water Wells rodticin over 100 00C Copy to DWR CCPCUA
r QR WATER SUPPLY WELLS ONLY: Permit Program,1611 MSC,Raleig ,NC 27695
Method of test: k
Yield(gpm) !€
f.3b.Disinfection type: k/O/ Amount:
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6.2018
=mm GW-1 i